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AppIIJAUs Wd,Bg1P>:pr�s�,11�1en Submitted Properly Completed. Be Sure To Sign The Application. <br /> FbR OFFICE USE: CCII�� 11 O APPLICATION s <br /> SAN JOAQUl ffoiL"Atansferable, Revocable,Suspendable) PUMP&WELL <br /> HEALTH D11WVI0bNMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) L4 WATER QUALITY ln/ <br /> Application is hereby made to the San JoaqulnL`ocalHealthDistrictforapermittoconstructand/orinstall the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address / o, "'y City/Town &-/W/T`LT c <br /> Owner's Name '� � '� Phone 2-3��`— f 7 <br /> Address `CG /�Z 4'T^<C c1211L-O 9�;2,4o City 1. <br /> Contractor's Name L 9 — ct License#32I Z Z Business Phone G 93e� <br /> Contractor's Address CGS PCEmergency Phone_. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 1Z DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ ~ <br /> xl <br /> DISTANCE TO NEAREST: Septic Tank1/6'f Sewer Lines Pit Privy 6` <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> m DOMESTIC/PRIVATE EhUhILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION R—GRAVEL PACK Depth of Grout Seal <br /> t <br /> ❑ CATHODIC PROTECTION 11�—ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information —p-�- �L <br /> E] GEOPHYSICAL Surface Seal Installed By eca-raL <br /> PUMP INSTALLATION: Contractor_ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call foE a Grou Inspection prior to grouting and a final inspection. <br /> Signed X Title: ( �'..^�-C��')"z�•i•� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEPARTMENT USE ONLY <br /> PHASE q <br /> Application Accepted By �"`' Date / <br /> Additional Comments: <br /> 4Phase II Grout Inspection Phase III Final Inspection <br /> P y ` " t Ins 1 , Date `AA <br /> Inspection B Date Inspection <br /> B <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �f AMOUNT <br /> FEE4/ 7 �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Lo 17 <br /> '^7 q I31� n,(tez'71 <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:.. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />